Anismus or pelvic floor dysynergia are terms to describe iconstipated patients who contract their anal sphincters on lattempting defecation, thus blocking rectal emptying. We saw 50 female patients (pts.) with constipation who had iitractable symptoms unresponsive to diet or laxatives !before referral. Sixteen pts. had evidence of anismus on anal sphincter EMG, defecography and anal manometry, 3 had idiopathic megarectum, 1 had Hirschsprung's and 30 had normal rectal emptying. Six of the 16

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... mus pts. were excluded; 4 had improvement with high fiber diet compliance plus self-monitoring of symptoms before therapy, and 2 ;refused therapy. Ten female pts. (age 17-38;mean 27 yr.) were randomly assigned to either general relaxation therapy (GRT) with external anal sphincter biofeedback (EASB) or GRT with "sham" BASB (biofeedback signals were random and NOT indicative of EAS muscle tension). Therapy was 2-3 hours daily for one week. Four pts. received GRT + EASB and 6 received GRT + sham EASB. All pts. completed diaries of stool frequency (SF), abdominal pain (AP) and bloating (B) for 4 weeks before and 12 weeks after therapy. Eight pts. improved with therapy at 12 weeks; 5/6 sham EASB and 3/4 active EASB. In the eight patients responding to therapy, weekly SF increased from 1.9 to 3.8 (p<0.05), mean weekly B decreased from 20 to 11 (p<0.05) and mean iweekly AP decreased from 14 to 8 (NS). For all 10 pts. iweekly SF increased from 1.8 to 3.3 (p<0.05), mean.weekly IB decreased from 19 to 12 (p<0.05) and mean weekly AP decreased from 13 to 10 (NS). Only 3 pts. (all sham BASB) had improved rectal emptying on defecography with relaxation on EMG post-therapy despite symptom relief in the other 5 pts. Despite anal sphincter EMG, defecography and anal manometry before and 12 weeks after therapy, no !parameter of rectal function predicted outcome with therapy. Relaxation therapy appears to be an important component for achieving symptomatic improvement in women with anismus. Since EASB was not evaluated separately it is difficult to assess its role in symptom response. As well, GRT + sham EASB may provide some increased sensitivity to anal function that would not occur with GRT alone. These results show that despite continued anismus on objective testing, pts. can improve symptomatically with this therapy. Increased anal sensitization and reduced anal muscle tension may be significant factors contributing to treatment success. Twenty-two patients with symptoms of obstructive defaecation were recruited for domiciliary biofeedback self-regulatory relaxation training. Each patient served as his or her own control for anorectal and proctographic assessments, before and after biofeedback treatment. Biofeedback training improved the obstructive symptoms of the patients. Significant changes in various parameters relating to the obstructive defaecation syndrome were observed before and after biofeedback management, as follows. The rectal sensory threshold was improved (p<0.05). The external anal sphincter wire EMG voltage recorded during simulated defaecation, via isotope proctography, was significantly reduced (p<0.0005), and this was associated with a greatly reduced anismus index (p<0.0001). The defaecation rate (% of evacuation/defaecation time) was significantly increased (p<0.05), the anorectal angles at rest and on attempted defaecation were made more obtuse (p<O.05) and the pelvic, floor movements, as examined byr isotope proctography were made more dynamic (p<0.03). Biofeedback thus improves the act of defaecation in patients suffering from inappropriate contraction of the pelvic floor and sphicter musculature. It appears that the modulating effects of the afferent and efferent sides of the defaecation reflex as well as its central control mechanism can be influenced by biofeedback self. regulatory means, which in turn leads to an improved quality of anorectal function. F235 Patients rendered incontinent by surgery exhibit evidence of combined internal and external anal sphincter injury Incontinence following anorectal surgery is characterised by low anal squeeze pressures and abnormal sphincter appearance on endoanal ultrasonography. Sixteen patients (11 male; median age 43 years, range 23-71) rendered incontinent following minor anal surgery and seventeen controls (7 male ; median age 31 years range 24-73) were assessed by ambulatory anal sphincter electromyography (EMG) and manometry. Endoanal sonography revealed internal sphincter division in 7 subjects, with combined injury to the external sphincter in two. The median internal sphincter EMG frequency was CONTROL 0.44 Hz. (0.36-0.48), TRAUMA 0.18 Hz. (0.11-0.22)(p<0.001). Resting anal pressures were lower in the incontinent group; median TRAUMA 35cm.H20 (18-62), CONTROL 90 cm.H20 (72-98)(p<0.001). Squeeze pressures were similarly low for the trauma patients; median TRAUMA 52 cm.H20 (28-74), CONTROLS median 234 cm.H20 (170-386)(p <0.001). The frequency of transient internal sphincter relaxation was TRAUMA median 8/hour (6-12), CONTROL median 5 (4-6)(p< 0.05). Recruitment of the external sphincter EMG in the incontinent group was poor in all patients during transient internal sphincter relaxation, measuring between 0-24 % (CONTROLS range 45 -120 %) (p<0.001) suggesting episodes of incontinence. Incontinence results because of combined internal and external sphincter injury. Such disruption is present despite the sphincters appearing intact in seven of the patients _studied.